Joint Commission keys to fight fatigue

In a recent Sentinel Event Alert, the Joint Commission accrediting organization offered suggestions for health care employers to "mitigate the risks of fatigue that result from extended work hours — and, therefore, protect patients from preventable adverse outcomes."

1. Assess your organization for fatigue-related risks. This includes an assessment of off-shift hours and consecutive shift work, and a review of staffing and other relevant policies to ensure they address extended work shifts and hours.

2. Since patient hand-offs are a time of high-risk — especially for fatigued staff — assess your organization's hand-off processes and procedures to ensure that they adequately protect patients.

3. Invite staff input into designing work schedules to minimize the potential for fatigue.

4. Create and implement a fatigue management plan that includes scientific strategies for fighting fatigue. These strategies can include:

• engaging in conversations with others (not just listening and nodding);

• doing something that involves physical action (even if it is just stretching);

• strategic caffeine consumption (don't use caffeine when you're already alert and avoid caffeine near bedtime);

• taking short naps (less than 45 minutes).

These strategies are derived from studies conducted by the National Aeronautics and Space Administration (NASA), which state that people can maximize their success by trying different combinations of countermeasures to find what works for them. The NASA studies stress that the only way to counteract the severe consequences of sleepiness is to sleep.

Strategies for determining shift durations and using caffeine to combat fatigue can be found in chapter 40 of "Patient Safety and Quality: An Evidence-Based Handbook for Nurses" (

5. Educate staff about sleep hygiene and the effects of fatigue on patient safety. Sleep hygiene includes getting enough sleep and taking naps, practicing good sleep habits (for example, engaging in a relaxing pre-sleep routine, such as yoga or reading), and avoiding food, alcohol or stimulants (such as caffeine) that can impact sleep.

6. Provide opportunities for staff to express concerns about fatigue. Support staff when appropriate concerns about fatigue are raised and take action to address those concerns.

7. Encourage teamwork as a strategy to support staff who work extended work shifts or hours and to protect patients from potential harm. For example, use a system of independent second checks for critical tasks or complex patients.

8. Consider fatigue as a potentially contributing factor when reviewing all adverse events.

For organizations with a current policy that allows for sleep breaks for staff defined as essential by the organization:

9. Assess the environment provided for sleep breaks to ensure that it fully protects sleep. Fully protecting sleep requires the provision of basic measures to ensure good quality sleep, including providing uninterrupted coverage of all responsibilities (including carrying pagers and phones, and coverage of both admissions and all continuing care by another provider), and providing a cool, dark, quiet, comfortable room, and, if necessary, use of eye mask and ear plugs.

[Editor's note: The Joint Commission alert is available at]